Presenter: Felicia Blocker Chair: Dabney Evans, PhD, MPH

Committee: Monique Hennink, PhD

Date: April 9, 2013

Canal Water and Clorox:Characterizing Cholera Risk Factors for

Haitian Migrants Living in the Dominican Republic

Agenda•Background•Research Question•Methods•Limitations•Results• Recommendation

s•Remaining Questions•Final Thoughts•Acknowledgements•Q & A Session

BackgroundHistory of Hispaniola •East colonized by the Spanish (Dominican) in 1492. •West colonized by the French (Haiti) in 1777. •French importation of slaves for sugar production.•Slave revolt in 1791. •Haiti declared an independent nation in 1804•Dominican vs. Haitian cultural dichotomy provides context for this study.

(Rogozinsky, 2000; Wucker, 1999)

What is Cholera?• Cholera is a diarrheal disease

transmitted through the ingestion of contaminated human fecal matter, usually through unwashed foods.

• John Snow described the disease as “traveling along the great tracks of human intercourse; never going faster than people travel, and generally, much more slowly. In extending to a fresh island or continent, it always appears first at a sea-port.”

(Snow, 1855)

Present Day HispaniolaCholera in Hispaniola Haitian Migrants in the D.R• January 2010 earthquake in

Port-au- Prince, Haiti initiating the increased migration of Haitians to the Dominican Republic (D.R)

• First Case of cholera in Haiti was reported on October 21, 2010.

• First case of cholera in the Dominican Republic was reported less than two weeks later on October 31, 2010.

• Migrants Compose a large part of the Dominican economy working mainly in the tourism, construction and sugar industries.

• Haitian migrants are a vulnerable population in the D.R, experiencing poverty, a lack of access to health care, and discrimination daily.

• Major outbreaks of cholera have occurred in mixed Haitian/ Dominican areas.

(Bartlett et al., 2011; CDC, 2010; Dominguez, 2011; Ferguson, 2006; Howard, 2007; Human Rights Watch, 2002; Kushner & Coto, 2011; PIH, 2010; Tappero & Tauxe, 2011; Tavernier, 2008)

Research Question

How does the context of poverty, lack of healthcare access and discrimination contribute to increased risk of cholera (compared with Dominican nationals) amongst Haitian migrants in the Dominican Republic?

MethodsMétodosMetòd

Study Methods

•Cross- sectional study design.•Data were collected through focus group

discussions (FGD) with Dominican and Haitian participants.▫A total of eight FGDs were conducted over

six weeks.▫FGDs were moderated in participant’s

native language by trained facilitators.▫Participants stratified by gender,

nationality and rural or urban location.

Study Population

Participants NumberAge

rangeUrban GroupsDominican Men

 5

 21- 48

Dominican Women

7 40-54

Haitian Men 6 26- 34

Haitian Women 6 19- 23

Rural GroupsDominican Men

 7

 23- 73

Dominican WomenHaitian Men Haitian Women

6 6

6

†18- 3325-38

Characteristics of Focus Group Discussion Participants† Indicates missing information

• The study took place in a rural village, and an urban barrio in the Duarte Province.

• Participants were recruited through the use of gate keepers in the community.

• Eligible participants identified as either a Haitian migrant to the Dominican Republic, or a native Dominican, were over 18 years of age, a resident of a mixed community in the Duarte Province, and able to give informed oral consent to be in a FGD.

Focus Group Discussion Guide• Introduction to the focus group• Explaining study purpose and laying ground rules.

• Community mapping activity• Ex: Where do Haitians Live? Where do you get

water from?• Free listing activity• Ex: What Can someone do to prevent getting

cholera?• Key questions• Ex: How has your community changed since

cholera came to the Dominican Republic?• Closing questions• Ex: Of all if the issues that we talked about today

which is the most important to you?• Conclusion

Data Preparation• Recording

• Transcribing & Translating

• Pre-Coding

• Parent Codes

• External Coding

• MaxQDA10 Software

• Grounded Theory Approach▫Using data to create a model explaining

behavior, not external theories.

Codebook Excerpt

MHMigrant Haitian Experiences

 

MH1

Haitians as Disease Carriers

Descriptions of Haitians as disease carriers. Disease could be cholera, HIV… Placing blame on Haitians for the emergence of diseases in the D.R

MH2

Haitian Documentation

Discussions of Haitian documentation issues- Deportation, illegal immigration, Haitian census

MH3

Haitian Employment

Describes the working conditions of Haitians, how much they get paid, type of work, Wealthy Dominicans need for working Haitians

MH4

Reasons for Immigration

Why do Haitians come to the DR?

Limitations▫Cross-sectional study design

Captures only one point in time Complete data were collected on as many

subsections of the population as possible.

▫Language barriers between Spanish and Kreyol speaking research assistants (R.A.), and the researcher Affects data collection In country collaborators helped explain tasks to

R.As and communicate R.A questions to the researchers

▫Power dynamics in FGDs Influences data quality During the introduction of the focus group,

R.As explained that all opinions were welcomed, and equally valid during the FGD.

ResultsResultadosRésultats

Poverty

“The Haitians just want you to take them to work…here to work in the rediodales working with shovels, one day is worth about 500, 600 pesos [$14-17 USD], one day, but for a Haitian no, the Haitian does it for even 300 pesos [$8.50 USD].”

- Rural Dominican Male

▫Poverty prevented rural Haitian migrants from being able to access running water in their homes and workplaces.

▫Many migrants did not have the resources to purchase treated bottled water, or the items needed to treat their water.

Healthcare“In our country some hospitals exist that are extremely precarious, you understand, they have very little, um…very few resources, and they have a low economic level and a low health because they get the poorest people.”

- Urban Dominican Male

▫The lack of access to quality care was a pervasive theme across all nationalities and geographical locations.

▫Provision of quality care was limited to individuals who could afford private insurance in private hospitals.

▫Public hospitals were free to everyone, but did not have the resources to provide quality care.

Impacts cholera severity, diagnosis and treatment if an individual is infected.

Discrimination“I personally have a boss who is an attorney. I used to work with him. When we first met, it used to be that our contact was warm, but since cholera came, he just shakes hands, no more close contact. He will give you everything but he just back up.”

- Rural Haitian Male

▫ Discrimination including structural and physical violence was described in every focus group with Haitian participants.

Impact on cholera risk for migrants.

▫ Anti-Haitian prejudices increased as Dominicans blamed Haitians for cholera in the Dominican Republic.

Risk Perception

“It’s [prevention behaviors] just a suggestion. I sometime see people practicing hygiene for themselves to avoid getting cholera, and I see those people who were practicing it get cholera. But I, who do not practice hygiene; I do not get it.”

- Urban Haitian Woman

▫ Participants expressed a general lack of risk perception.

▫ Urban Haitian women and Dominicans: prevention behaviors don’t affect risk.

▫ Rural migrants and urban Haitian men: lack of cholera knowledge.

Impacts cholera transmission risk.

RecommendationsRecomendacionesRecommandations

Increased Access to Treated Water

Short Term Long Term

Providing supplies needed to treat water such as bleach and purifying tablets for migrants at a reduced cost.

Incentivizing rural venders to lower prices of treated bottled water.

Increased Access to Quality Care

Short Term Long Term

Increasing surveillance efforts, and urging individuals to go to hospitals and complete medical testing specifically for any cholera-like symptoms.

Raising level of care at public hospitals through increased funding and personnel training.

Reducing Haitian Stigma

Short Term Long Term

Translating cholera research into community based interventions.

Providing necessary education to transform widely held norms that portray Haitian migrants as disease carriers.

Risk Perception

Short Term Long Term

Increasing health promotion programs designed to raise awareness about cholera in both Haitian and Dominican communities in the Duarte Province.

Creating culturally appropriate education materials for Dominicans and Haitian migrants, and notifying the public of new cholera cases.

Remaining Questions• How would future studies benefit from considering

the condition of Dominican facilities and the structure of the national healthcare system, when examining barriers to care?

• What are migrants’ reactions to increased

discrimination?

• What are the most efficacious ways to reduce anti-Haitian prejudices?

• Could community-based participatory research be the key in the creation of culturally appropriate health promotion messages?

Final Thoughts

•The Greatest needs in the study population: ▫Access to potable water

Municipal Affordable treated, bottled

▫Culturally appropriate cholera education Messages for Haitians and Dominicans Delivered in churches, schools, and

neighborhood common areas

AcknowledgementsReconocimientos

Rekonesans

• Thesis Advisor• Dabney Evans,

PhD, MPH• Thesis Committee

Member• Monique

Hennink, PhD• Research Peers• Hunter Keys • Stephanie

Leventhal• Andrea Lund

• Field Advisor• Rosa Burgos, MA

• Research Assistants• Study Participants• Rollins Peers• Family and Friends

Thank you!¡Muchas gracias! Mèsi anpil!

Questions? ¿Preguntas?

Kesyons?